Five- and six-strand hamstring grafts consistently produce appropriate graft diameters for anterior cruciate ligament reconstruction

The effectiveness of quadrupled semitendinosus graft technique in anterior cruciate ligament reconstruction: A network meta-analysis assessing various graft preparation techniques

PURPOSE

This study aims to perform a network meta-analysis of hamstring graft preparation techniques to enhance anterior cruciate ligament (ACL) reconstruction guidelines and inform clinical decision-making in patients with primary ACL rupture.

METHODS

A review of the literature, from 1 January 1990, to 31 August 2023, was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, focusing on the clinical outcomes of various hamstring graft preparation techniques. Forty-six studies (over 4800 knees) were analysed. Eight graft compositions: doubled hamstring (ST/G)-1978 grafts, doubled hamstring with augmentation (ST/G+A)-586 grafts, tripled semitendinosus (3ST)-124 grafts, quadrupled semitendinosus (4ST)-1273 grafts, five-strand tripled semitendinosus + doubled gracilis (3ST/2GR-839 grafts, six-strand tripled semitendinosus + tripled gracilis (3ST/3GR)-335 grafts, seven-strand quadrupled semitendinosus + tripled gracilis (4ST/3GR)-11 grafts and ≥eight strands-24 grafts were compared, considering graft sizes, laxity, muscle strength, range-of-motion, patient-reported outcome measures (PROMs), return to sport (RTS) and adverse events.

RESULTS

The 4ST grafts fared better than the ST/G grafts in the International Knee Documentation Committee (IKDC), Knee Injury and Osteoarthritis Outcome Score (KOOS) Sport, KOOS Q and RTS (mean difference [MD], -1.69; p = 0.0159; MD, -1.55; p = 0.0325; MD, -1.93; p = 0.001; odds ratio: 3.13; p < 0.0001). The IKDC differed significantly between the 4ST and ST/G+A groups (MD, 1.88; p = 0.046). The ST/G+A resulted in the lowest knee laxity, surpassing the ST/G, 3ST and 4ST. The ST/G had the smallest diameter (ST/G vs. ST/G+A: MD, 1.26; 95% confidence interval [CI]: 0.67-1.86, p < 0.0001). Reduced failure rates were noted with the 3ST/2GR (3ST/2GR vs. ST/G: MD, 6.93; p = 0.009) and 3ST/3GR (3ST/3GR vs. ST/G: MD, 53.64; p = 0.006).

CONCLUSION

The ideal hamstring graft for ACLR should be individualized. A 4ST graft is likely to yield good PROMs. For high stability and rapid RTS, adding augmentation to the graft is advisable. The ST/G is the thinnest graft possible.

LEVEL OF EVIDENCE

Network meta-analysis of level I-III studies.

Single bundle hamstrings autograft preparation techniques for anterior cruciate ligament reconstruction: current concepts

Anterior cruciate ligament reconstruction (ACLR) is one of the most common orthopedic procedures, and huge variation exists in the surgical technique. Single bundle hamstrings autograft reconstruction is a common method and has good clinical outcomes. A criticism of the hamstrings autograft is a small graft diameter, often less than 8-mm, which has been associated with increased re-rupture rates. Several graft preparation techniques for single bundle hamstrings autograft exist. Perioperative decisions include the number of tendons utilized, number of graft strands, graft configuration, and femoral and tibial fixation methods. Awareness of the minimum tendon and graft length required to produce each graft variation is necessary to avoid common pitfalls. However, intraoperative graft modification is possible to maximize graft diameter, and obtain proper fixation. The objective of this current concepts review is to describe the indications, surgical anatomy, technique, intraoperative tips, clinical outcomes, and complications for single bundle hamstrings autograft preparation techniques in ACLR.

Tendon cross-sectional area on magnetic resonance imaging and anthropometric characteristics can be used to predict insufficient four-strand hamstring autograft diameter in anterior cruciate ligament reconstruction: A systematic review

PURPOSE

To evaluate the utility of semitendinosus tendon (ST) and gracilis tendon (GT) cross-sectional area (CSA) on magnetic resonance imaging (MRI) and anthropometric characteristics in preoperative estimation of graft diameter in patients undergoing anterior cruciate ligament reconstruction (ACLR) with four-strand hamstring autografts.

METHODS

Three databases were searched on 29 August 2023. The authors adhered to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and R-AMSTAR (Revised Assessment of Multiple Systematic Review) guidelines and the Cochrane Handbook for Systematic Reviews of Interventions. Data on demographics, anthropometric characteristics, imaging techniques, tendon CSA, correlation coefficients, sensitivities, specificities, regression models and cutoffs for predicting intraoperative graft diameters above 8 mm were recorded.

RESULTS

Forty-six studies comprising 4140 patients were included. Twelve of 19 (63.2%) studies reporting on ST + GT CSA found a moderate to very high correlation with intraoperative graft diameter. Five of 10 (50%) and one of seven (14.3%) studies reporting on ST CSA and GT CSA, respectively, found a moderate to high correlation with intraoperative graft diameter. Cutoffs of ST + GT CSA for predicting graft diameters above 8 mm ranged from 15.8 to 31.2 mm2. Nine of 35 (25.7%) studies that reported on height found a moderate to very high correlation with graft diameter. Seven of 33 (21.2%) studies reporting on weight found a moderate correlation with graft diameter.

CONCLUSION

Of the MRI parameters assessed, ST + GT CSA was the most reliable predictor of graft diameter. However, cutoffs, sensitivities, and specificities for predicting diameters above 8 mm were highly variable. Anthropometric characteristics in general were less predictive of graft diameter than MRI parameters. This information can be used by clinicians to predict patients at risk for ACLR failure due to insufficient graft size.

LEVEL OF EVIDENCE

Level IV.

Estimated diameter increase from a 4S to a 6S hamstring graft configuration - A cadaveric study

PURPOSE

Graft diameter in anterior cruciate ligament reconstructions has been shown to influence the risk of failure. It is therefore important to be able to adjust the graft configuration to modify the diameter. To measure the impact of a 6-strand (6S) hamstring autograft configuration on graft diameter compared to the standard 4-strand (4S) configuration.

METHODS

Cadaveric study on 33 knees, using the usual hamstring graft harvesting technique. Semitendinosus and gracilis tendons were harvested and their length, width, and diameter were measured in 4S and 6S configurations separately by three evaluators.

RESULTS

6S configuration leads to a median increase of 1.5 (range: 0.0-2.0) mm in diameter compared to 4S (p < 0.001). A graft diameter of more than 8 mm is attained in less than a third of 4S grafts within this population in comparison to 84% when the 6S configuration is used.

DISCUSSION

The 6S hamstring graft configuration increases the graft diameter by a median of 1.5 millimeters compared to the traditional 4S configuration. It can reliably be used to obtain an 8.5 mm graft diameter or more in cases where the semitendinosus measures at least 270.5 mm and the 4S configuration has a diameter of 7.5 mm or 8 mm. This information helps to better delineate the impact of a 6S configuration in a pre-operative or intra-operative setting to optimize the decisional process and surgical flow and to easily adapt the graft diameter.

LEVEL OF EVIDENCE

V (cadaveric study).

Small Hamstring Tendon Graft for Anterior Cruciate Ligament Reconstruction Combined With Anterolateral Ligament Reconstruction Results in the Same Failure Rate as Larger Hamstring Tendon Graft Reconstruction Alone

PURPOSE

To compare patients undergoing anterior cruciate ligament (ACL) reconstruction with hamstring grafts 7 mm or less in diameter combined with anterolateral ligament (ALL) reconstruction versus isolated ACL reconstruction with grafts greater than 7 mm in diameter.

METHODS

We retrospectively evaluated the descriptive data and clinical outcomes of patients who underwent primary ACL reconstruction with hamstring grafts from June 2013 to January 2020 and had a minimum follow-up period of 2 years. Patients with quadrupled or quintupled semitendinosus and gracilis autograft 7 mm or less in diameter combined with single-strand ALL reconstruction (ACL-ALL group) were matched in a 1:2 propensity ratio to patients who underwent isolated single-bundle ACL reconstruction with hamstring grafts greater than 7 mm (ACL group).

RESULTS

We identified 30 patients in our database who met the criteria for the ACL-ALL group. The patients in this group were matched to 60 patients comprising the ACL group. Both groups were similar regarding all preoperative matched and unmatched variables. The mean ACL graft diameter was 6.8 ± 0.4 mm in the ACL-ALL group and 8.6 ± 0.6 mm in the ACL group (P < .001). The ACL-ALL group presented 1 failure (3.3%), and the ACL group presented 3 failures (5%) (P = .717). Postoperative KT-1000 measurements were similar between the groups (2.1 ± 1.1 mm vs 1.9 ± 1.2 mm, P = .114), as were postoperative pivot-shift grades (P = .652). Subjective International Knee Documentation Committee scores and Lysholm scores did not present any differences between the groups (P = .058 and P = .280, respectively).

CONCLUSIONS

Patients who undergo combined ACL-ALL reconstruction with an ACL graft diameter of 7 mm or less can achieve similar results to patients who undergo isolated ACL reconstruction with a graft diameter greater than 7 mm. An associated ALL reconstruction can be performed to increase knee stability in patients with small-diameter hamstring grafts.

LEVEL OF EVIDENCE

Level III, retrospective, comparative therapeutic trial.

Remnant preserving ACL reconstruction with a functional remnant is related to improved laxity but not to improved clinical outcomes in comparison to a nonfunctional remnant

PURPOSE

The Anterior cruciate ligament (ACL) remnant has been pointed out as a ligamentization enhancer. Nonetheless, the remaining tissue can be functional if it still provides some stability or nonfunctional. This study intends to compare the clinical results and knee stability of functional vs. nonfunctional remnant preservation ACL reconstruction (ACLR).

METHODS

One hundred and seventy-five patients with ACL injuries were included and underwent remnant preservation ACLR. They were divided into two groups accordingly to remnant tissue functionality: functional (Group F) and nonfunctional (Group NF). Primary outcome was defined as patient reported outcomes measured with Lysholm, IKDC and Tegner continuous scales and improvements. Secondary outcomes comprised of Lachman test, anterior drawer test, pivot shift test, extension and flexion deficit, graft coverage by remnant preserved tissue and failure rate (persistent instability or new ACL lesion). Menisci lesions, cartilage lesions and time to surgery were also recorded for each group.

RESULTS

One hundred and forty-four patients were available at a mean of 30.2 ± 10.1 months: 69 Functional and 75 Nonfunctional. Lysholm, IKDC and Tegner functional outcomes demonstrated no difference between the groups, Functional compared to Nonfunctional: 88.4 ± 10.5 vs. 92.2 ± 4.9, n.s. and 83.2 ± 11.3 vs. 87 ± 5.3, n.s. and 6 (5-10) vs. 6 (5-9), n.s., respectively. Lysholm and IKDC functional outcomes improvements demonstrated differences between the groups: Functional compared to Nonfunctional (39.3 ± 9.4 vs. 42.3 ± 7.4, p = 0.014 and 37.7 ± 10 vs. 41.0 ± 6.6, p = 0.032); however, they were not clinically significant. Functional group showed more stability on physical examination pre- and post-operatively (p < 0.001, p < 0.001). There was no difference regarding extension deficit (n.s.); however, functional group had more flexion deficit (p = 0.02). Nonfunctional group had better graft coverage (p = 0.001). There was no difference regarding failure rate: 4% vs. 9%, (n.s.).

CONCLUSION

Both remnant preservation ACLR techniques were able to achieve satisfactory functional outcomes. A functional remnant was not related to improved functional outcomes in comparison to a nonfunctional remnant; however, it was related to less laxity pre and postoperatively and inferior graft coverage.

LEVEL OF EVIDENCE

II.

Addition of the Sartorius Tendon Improves Biomechanics of a Four-Strand Hamstring Anterior Cruciate Ligament Autograft

PURPOSE

The purpose of this study was to quantify and compare the biomechanical properties and change in graft size when adding the sartorius tendon as a fifth strand to a four-strand ST-G hamstring autograft. Additionally, the sartorius tendon was tested individually to quantify its independent biomechanical properties.

METHODS

Four-strand and five-strand hamstring tendon grafts were harvested from matched cadaveric knees (mean age: 81.6 ± 9.8). These matched grafts were biomechanically tested using a MTS servohydraulic test system at a rate of testing representative of physiologic tears. The mean diameter, cross-sectional area, and ultimate load to failure were quantified and compared with a one-sided, paired Student's t-test. A P < .05 was considered statistically significant.

RESULTS

The mean diameter of the five-strand graft was significantly larger than the four-strand graft (9.30 ± .84 mm vs 8.10 ± .42 mm; P = .002). The average ultimate load to failure of the five-strand graft was 65.3% higher than the four-strand graft (2984.05 ± 1085.11 N vs. 1805.03 ± 557.69 N; P = .009) and added 14.8% to the diameter of the four strand ST-G autograft.

CONCLUSIONS

The addition of the sartorius tendon to a four-strand hamstring autograft significantly increased ultimate load to failure by 65%, graft cross-sectional area by 32%, and graft diameter by 15% compared to a traditional four-strand ST-G autograft. This information can be helpful to surgeons who wish to improve the strength of a four-strand ST-G autograft and for undersized grafts as an alternative to allograft supplementation.

CLINICAL RELEVANCE

The addition of the sartorius to the four-strand ST-G hamstring autograft significantly increases the ultimate load to failure and overall graft diameter, which can be particularly helpful in undersized autografts as an alternative to allograft supplementation.

Quadriceps Tendon Autograft in Pediatric ACL Reconstruction: Graft Dimensions and Prediction of Size on Preoperative MRI

Background

There is increased interest in quadriceps autograft anterior cruciate ligament (ACL) reconstruction in the pediatric population.

Purpose

To evaluate children and adolescents who underwent ACL reconstruction using a quadriceps autograft to determine the properties of the harvested graft and to assess the value of demographic, anthropometric, and magnetic resonance imaging (MRI) measurements in predicting the graft size preoperatively.

Study Design

Cross-sectional study; Level of evidence, 3.

Methods

A retrospective database search was performed from January 2018 through October 2020 for patients undergoing ACL reconstruction. Patients <18 years old at the time of surgery in whom a quadriceps tendon autograft was used were selected. Demographic data and anthropometric measurements were recorded, and graft measurements were abstracted from the operative notes. Knee MRI scans were reviewed to measure the quadriceps tendon thickness on sagittal cuts. Graft length and diameter were then correlated with anthropometric and radiographic data.

Results

A total of 169 patients (98 male) were included in the final analysis, with a median age of 15 years (range, 9-17 years). A tendon length ≥65 mm was harvested in 159 (94%) patients. The final graft diameter was 8.4 ± 0.7 mm (mean ± SD; range, 7-11 mm). All patients had a graft diameter ≥7 mm, and 139 (82%) had a diameter ≥8 mm. Preconditioning decreased the graft diameter by a mean 0.67 ± 0.23 mm. Age (P = .04) and quadriceps thickness on MRI (P = .003) were significant predictors of the final graft diameter. An MRI sagittal thickness >6.7 mm was 97.4% sensitive for obtaining a graft ≥8 mm in diameter.

Conclusion

Our findings suggest that tendon-only quadriceps autograft is a reliable graft source in pediatric ACL reconstruction, yielding a graft diameter ≥8 mm in 82% of pediatric patients. Furthermore, preoperative MRI measurements can be reliably used to predict a graft of adequate diameter in children and adolescents undergoing ACL reconstruction, with a sagittal thickness >6.7 mm being highly predictive of a final graft size ≥8 mm.